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Drugs and Biologicals RETIRED

Medicare Coverage Articles

Medicare Policies and Guildelines

Article

Generally, drugs and biologicals are covered only if all of the following requirements are met:

� They meet the definition of drugs or biologicals;

� They are of the type that cannot be self-administered;

� They meet all the general requirements for coverage of items as incident to a physician's services;

� They are reasonable and necessary for the diagnosis or treatment of the illness or injury for which they are administered according to accepted standards of medical practice;

� They are not excluded as immunizations; and

� They have not been determined by the FDA to be less than effective.

Drugs that are usually self-administered by the patient, such as those in pill form, or are used for self-injection, are generally not covered by Part B. However, there are a limited number of self-administered drugs that are covered because the Medicare statute explicitly provides coverage. Examples of drugs that are usually self-administered by the patient and are covered include: blood clotting factors, drugs used in immunosuppressive therapy, erythropoietin for dialysis patients, osteoporosis drugs for certain homebound patients, and certain oral cancer drugs.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

If the "J" code descriptor can be multiplied to reflect the dosage being administered, use the J-code, with the appropriate number of units, that reflects the dosage given.

It is not appropriate to use the "J" code with a multiplier in the units' field, when there is another "J" code, which more closely describes the amount given.

It is not appropriate to bill for the full amount of a drug when it has been split between two or more patients. Bill only for the amount given to each beneficiary.

NOC codes should only be used for those drugs which do not have a "J" code, which describes the drug being administered or is not a multiple of the "J" code being
administered.

1. When appropriate, the NOC code is selected based upon the antineoplastic nature or otherwise therapeutic value of the drug as follows:

� J9999 Not otherwise classified, antineoplastic drug

� 90799 Unlisted therapeutic, prophylactic or diagnostic injection

2. When billing with an NOC code, include on the claim, the narrative description reflective of the agent and the dose administered.

Payment for the administration of an injection is included in the payment for the office visit or any other service performed on that day. However, the administration may be paid when performed independently.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not medically reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, Section 1861(s)(2)(A)
This section allows coverage and payment for services and supplies (including drugs and biologicals which are not usually self-administered by the patient) furnished as an incident to a physician's professional service, of kinds which are commonly furnished in physicians' offices and are commonly either rendered without charge or included in the physicians' bills.

� Medicare Benefit Policy Manual, Pub.100-2, Chapter 1, �30 for drugs and biologicals

� Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, Section 50, and Chapter 17, Section 10. This section addresses coverage and limitations for drugs and biologicals.

� Medicare Benefit Policy Manual, Pub.100-2, Chapter 16, �20 for service not reasonable and necessary

� Medicare Program Integrity Manual, Pub.100-8, Chapter 13 �13.7.1 for evidence supporting LCD

� Medicare Program Integrity Manual, Pub.100-8, Chapter 13 �13.5.4 for LCD requirements that alternative services be tried first

Additional Information:

This Article was converted from an LMRP on 01/05/2005

01/29/2005 - CPT/HCPCS code J0151 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0286 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0340 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0400 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0510 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0590 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0635 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0695 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0730 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0810 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1050 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1090 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1095 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1362 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1561 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1690 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1739 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1741 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1755 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1820 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1910 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1930 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1970 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2000 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2240 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2330 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2350 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2352 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2480 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2500 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2512 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2640 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2860 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2915 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2970 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3080 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3245 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3270 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3390 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3395 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3450 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7315 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7316 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7508 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7618 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7619 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7621 was deleted from group 1
01/29/2005 - CPT/HCPCS code J9180 was deleted from group 1

History:

11/26/2005 - The description for CPT/HCPCS code J7340 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7342 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7343 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7344 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7350 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7626 was changed in group 1

11/26/2005 - CPT/HCPCS code J0880 was deleted from group 1
11/26/2005 - CPT/HCPCS code J1563 was deleted from group 1
11/26/2005 - CPT/HCPCS code J1564 was deleted from group 1
11/26/2005 - CPT/HCPCS code J1750 was deleted from group 1
11/26/2005 - CPT/HCPCS code J2324 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7051 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7317 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7320 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7616 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7617 was deleted from group 1

Coverage Topic:

Chemotherapy (Inpatient)
Chemotherapy (Outpatient)

Bill Code:

999 - Not Applicable

Revenue Code:

99999 - Not Applicable

Article Information

Article ID/Type:

A24854/Article

Latest Revision Effective Date:

April 05, 2002

Original Effective Date:

April 05, 2002

Key Article:

Primary Jurisdiction:

State(Consortium/Region)
Puerto Rico(Northeast/Region II)

Secondary Jurisdiction:

State(Consortium/Region)

Contractor Information:

Contractor Name(Contractor Number)
Triple-S, Inc.(00973)

ICD-9 Covered

Not Specified

ICD-9 NOT Covered